Form 26.1 "Certificate of Physician for Involuntary Treatment for Alcohol and Other Drug Abuse" - Butler County, Ohio

What Is Form 26.1?

This is a legal form that was released by the Probate Court - Butler County, Ohio - a government authority operating within Ohio. The form may be used strictly within Butler County. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2016;
  • The latest edition provided by the Probate Court - Butler County, Ohio;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 26.1 by clicking the link below or browse more documents and templates provided by the Probate Court - Butler County, Ohio.

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Download Form 26.1 "Certificate of Physician for Involuntary Treatment for Alcohol and Other Drug Abuse" - Butler County, Ohio

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PROBATE COURT OF BUTLER COUNTY, OHIO
IN THE INTEREST OF:
Case No.
CERTIFICATE OF PHYSICIAN
[R.C. 5119.92 AND 5119.93(C)(1)]
Affiant states that he/she is a Physician as defined in Chapter 4731 of the Revised Code.
Affiant states that he/she examined the above named Respondent on:
and based on that examination, in his/her professional opinion, the Respondent:
does
does not
suffer from alcohol and/or drug abuse
does
does not
present an imminent danger or imminent threat of danger to self, family,
or others if not treated
does
does not
present a substantial likelihood of such a threat in the near future; and
can
cannot
reasonably benefit from treatment
The facts that support Affiant’s belief that Respondent does suffer from alcohol and/or drug abuse
and the need for treatment:
Type of Treatment:
Inpatient
Outpatient
Length of Treatment:
FORM 26.1 –CERTIFICATE OF PHYSICIAN
Effective: July 1, 2016
PROBATE COURT OF BUTLER COUNTY, OHIO
IN THE INTEREST OF:
Case No.
CERTIFICATE OF PHYSICIAN
[R.C. 5119.92 AND 5119.93(C)(1)]
Affiant states that he/she is a Physician as defined in Chapter 4731 of the Revised Code.
Affiant states that he/she examined the above named Respondent on:
and based on that examination, in his/her professional opinion, the Respondent:
does
does not
suffer from alcohol and/or drug abuse
does
does not
present an imminent danger or imminent threat of danger to self, family,
or others if not treated
does
does not
present a substantial likelihood of such a threat in the near future; and
can
cannot
reasonably benefit from treatment
The facts that support Affiant’s belief that Respondent does suffer from alcohol and/or drug abuse
and the need for treatment:
Type of Treatment:
Inpatient
Outpatient
Length of Treatment:
FORM 26.1 –CERTIFICATE OF PHYSICIAN
Effective: July 1, 2016
CASE NO.
Affiant further certifies that he/she knows that the following treatment facilities are willing and able to
provide the recommended treatment:
Name of Treatment Provider
Telephone Number of Treatment Provider
Name of Treatment Provider
Telephone Number of Treatment Provider
Name of Treatment Provider
Telephone Number of Treatment Provider
Physician’s Signature
Name and Title of Physician (Please Print)
Telephone Number of Physician
License Number of Physician
FORM 26.1 – CERTIFICATE OF PHYSICIAN
Effective Date: July 1, 2016
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